Daily Pain, Physical Activity, and Home Fluid Intake in Pediatric Sickle Cell Disease

Temporal summation of pain in sickle cell disease: comparison of adolescents and young adults with chronic vs. infrequent pain

OBJECTIVE

This study examined the role of central sensitization in the experience of pain among adolescents and young adults with the most severe genotypes of sickle cell disease (SCD). We hypothesized that adolescents and young adults with chronic SCD pain would demonstrate a higher perceptual response to repeated stimulation of identical intensity (i.e., temporal summation of pain, TSP) compared to counterparts with infrequent pain. We also examined psychological risk factors that can impact pain sensitivity.

METHODS

Patients ages 12-21 years, diagnosed with SCD type Hb SS or Hb S Beta0Thalasemia, who reported infrequent pain (≤2 pain days/month; n = 25) or met AAPT criteria for chronic SCD pain (n = 25) were enrolled. Patients were age- and sex-matched, with similar proportions receiving chronic blood transfusion and hydroxyurea. Patients completed static quantitative sensory testing (QST) and dynamic TSP testing to assess pain sensitivity. Patients and a caregiver completed demographic and psychological measures (depression, anxiety, pain interference, pain catastrophizing).

RESULTS

Simple slope analysis revealed differentially elevated heat TSP among adolescents and young adults with chronic SCD pain (b = 3.14, p = .002) but not those with infrequent pain (b = 0.45, p = .61). Faster habituation was further observed for those with chronic compared to infrequent pain. Adolescents and young adults with chronic pain reported more frequent depression, anxiety, and pain interference symptoms; however, psychological symptoms and pain catastrophizing were not associated with QST or TSP (ps >.17).

CONCLUSION

Current results demonstrate that a well-established, prognostic, QST risk marker (i.e., TSP) may distinguish chronic from infrequent pain subgroups of adolescents and young adults with SCD.

What interval of daily pain assessment is required to reliably diagnose chronic pain in SCD? The Pain in Sickle Cell Epidemiology Study

Objectives

Chronic pain in SCD has been defined as pain on most days over 6 months. In the landmark Pain in Sickle Cell Epidemiology Study, 60% of patients submitted <5 of the expected 6 months of pain diaries. Identifying chronic SCD pain using this long daily assessment interval is impractical. We therefore examined whether shorter, less burdensome intervals could accurately identify chronic SCD pain.

Methods

As the gold-standard sample, we chose the 116 Pain in Sickle Cell Epidemiology Study patients who submitted >5 months of diaries (153) and >49% of diaries during all months from 1 to 4. Using the same dataset, we tested daily diary assessment over shorter intervals: 2 weeks, 1 month, 2 months, 3 months, and 4 months. We defined chronic pain as intensity rated as >0 on >50% of diary days, regardless of interval. We then calculated the sensitivity and specificity of each diary interval.

Results

Among the gold-standard sample, 51.3% of patients had diary-defined chronic pain. Collection intervals of 2 months or more yielded similar chronic pain prevalences with identically high sensitivity (98.3%) and specificity (93%). Intervals of 1 month and 2 weeks yielded increasingly lower specificity (80.7%, 73.7%, respectively), but preserved sensitivity (≥96.6%).

Conclusion

In the Pain in Sickle Cell Epidemiology Study, intervals of 2 months or more of daily diary collection yielded high sensitivity and specificity, compared to an interval of 5-6 months. One may reasonably diagnose chronic SCD pain using 2 months of daily diaries.

Content validation of observer-reported sickle cell pain diaries (SCPD-CS and SCPD-CN): results from interviews with caregivers

BACKGROUND

Patients with sickle cell disease (SCD) experience daily pain and acute episodes known as sickle cell pain crises (SCPCs). The Sickle Cell Pain Diary-Caregiver Report (SCPD-C) is an observer-reported diary for use by caregivers of children ages < 12 years with SCD. This study reports on the content validity of the SCPD-C.

METHODS

The SCPD-C was developed based on a literature review, measurement expert input, and a patient advisory board including clinicians. Three rounds of interviews (including both concept elicitation and cognitive debriefing methodologies) were conducted with caregivers of children with SCD aged < 12 to evaluate the content validity of the SCPD-C.

RESULTS

Across three rounds of interviews, caregivers confirmed concepts in the SCPD-C and described observed impacts that were important and were added. Overall, caregivers evaluated the SCPD-C as easy to understand, with some minor adaptations for clarity. Additionally, the diary was split into two versions based on the child's age and school enrollment status (SCPD-CS for school-aged and SCPD-CN for non-school age children).

CONCLUSIONS

Caregivers provided valuable input that led to important additions and changes to the measures. The SCPD-CS and SCPD-CN are appropriate and fit-for-purpose observer-reported outcome measures of SCPC-related pain frequency and severity, and impacts on health-related quality of life.

Caregiver-Child Discrepancies in Reports of Child Emotional Symptoms in Pediatric Chronic Pain

OBJECTIVE

Pediatric chronic pain evaluation includes self-reports and/or caregiver proxy-reports across biopsychosocial domains. Limited data exist on the effects of caregiver-child discrepancies in pediatric pain assessment. In children with chronic pain, we examined associations among discrepancies in caregiver-child reports of child anxiety and depressive symptoms and child functional impairment.

METHODS

Participants were 202 children (Mage=14.49 ± 2.38 years; 68.8% female) with chronic pain and their caregivers (95.5% female). Children and caregivers completed the Revised Child Anxiety and Depression Scale (RCADS) and RCADS-Parent, respectively. Children also completed the Functional Disability Inventory. Mean difference tests examined caregiver-child discrepancies. Moderation analyses examined whether associations between child self-reported anxiety and depressive symptoms and functional impairment varied as a function of caregiver proxy-report.

RESULTS

Children reported more anxiety and depressive symptoms compared with their caregivers' proxy-reports (Z = -4.83, p < .001). Both informants' reports of child anxiety and depressive symptoms were associated with child functional impairment (rs = .44, rs = .30, p < .001). Caregiver proxy-report moderated associations between child-reported anxiety and depressive symptoms and functional impairment (B = -0.007, p = .003). When caregiver proxy-report was low, child self-reported anxiety and depressive symptoms were positively related to functional impairment (B = 0.28, SE = 0.07, 95% CI [0.15, 0.41], p < .001).

CONCLUSIONS

Discrepant caregiver-child perceptions of child anxiety and depressive symptoms may be associated with functioning in children with chronic pain, especially when caregivers report less child internalizing symptoms. These findings highlight the need for further examination of the effects of caregiver-child discrepancies on pediatric chronic pain outcomes and may indicate targets for intervention.

Systematic Review: Pain and Emotional Functioning in Pediatric Sickle Cell Disease

The objective of this systematic review was to assess the relationship between pain (frequency/intensity/duration, impairment, coping) and emotional functioning in pediatric Sickle Cell Disease, and evaluate the state of the literature. Studies were included if they met each of the following criteria: (a) primarily pediatric sample of youth or young adults up to age 21 years with SCD, (b) examined emotional functioning including anxiety and/or depressive and/or internalizing symptoms, and/or affect, (c) examined pain intensity/frequency/duration and/or pain-related impairment and/or pain coping as it relates to emotional functioning, as defined above. Using the established guidelines for systematic reviews, we searched PsycINFO, PubMED, and CINAHL databases for studies published through June 2018. Screening resulted in 33 studies meeting inclusion criteria. Study data were extracted and evaluated for scientific merit, resulting in four studies being removed. 29 studies were included in the final synthesis. Studies provide strongest evidence of a relationship between increased pain frequency and higher depressive and anxiety symptoms. There are moderate-to-strong associations between pain-related impairment and depressive symptoms, and small-to-strong associations between pain-related impairment and anxiety. When examining pain-coping strategies, maladaptive cognitive strategies show the strongest association with emotional functioning. There is a need for more adequately powered, prospective studies based on theoretical frameworks in order to advance our understanding of the relationship between pain and emotional functioning in pediatric SCD.

Emotion-Focused Avoidance Coping Mediates the Association Between Pain and Health-Related Quality of Life in Children With Sickle Cell Disease

Sickle cell disease (SCD) is associated with pain and decreased health-related quality of life (HRQOL). Coping strategies influence pain but have not been evaluated as mediating the relation between pain and HRQOL in pediatric SCD. The current study examined whether pain-related coping mediates the association between pain and HRQOL in children and adolescents with SCD. In total, 104 children and adolescents 8 to 18 years of age (Mage=12.93 y) with SCD attending outpatient clinics completed pain intensity, HRQOL, and pain-related coping measures. Multiple mediation analyses were used to examine whether pain-related coping mediated the pain and HRQOL relation and whether types of coping (ie, approach, emotion-focused avoidance, problem-focused avoidance) were independent mediators. Total indirect effects for models examining physical and psychosocial HRQOL were not significant. After controlling for covariates, emotion-focused avoidance significantly mediated the association between pain and physical HRQOL (effect: -0.023; bootstrapped SE: 0.018; 95% confidence interval: -0.0751, -0.0003) but not the pain and psychosocial HRQOL relation. Approach and problem-focused avoidance were not significant mediators. Coping with pain in pediatric SCD is an important avenue for clinical intervention and additional research. Among children with SCD reporting high pain intensity, interventions should emphasize negative impacts of emotion-focused avoidance coping and integrate other empirically supported coping strategies to improve HRQOL.

Predictive Ability of Intermittent Daily Sickle Cell Pain Assessment: The PiSCES Project

Background

Pain diary assessment in sickle cell disease (SCD) may be expensive and impose a high respondent burden.

Objective

To report whether intermittent assessment could substitute for continuous daily pain assessment in SCD.

Design

Prospective cohort study.

Setting

Academic and community practices in Virginia. Patients. A total of 125 SCD patients age 16 years or older in the Pain in Sickle Cell Epidemiology Study. Measurements. Using pain measures that summarized all diaries as the gold standard, we tested the statistical equivalence of four alternative strategies that summarized diaries only from the week prior or the month prior to study completion; one week per month; or one day per week (random day). Summary measures included percent pain days, percent crisis days (self-defined), mean pain (0-9 Likert scale) on all days, and mean pain on pain days. Equivalence tests included comparisons of means, regression intercepts, and slopes, as well as measurement of R2.

Results

Compared with the gold standard, the one-day-per-week and one-week-per-month strategies yielded statistically equivalent means of six summary pain measures, and the week prior and month prior yielded equivalent means as some of the measures. Regression showed statistically equivalent slopes and intercepts to the gold standard using one-day-per-week and one-week-per-month strategies for percent pain days and percent crisis days, but almost no other equivalence. R2 values ranged from 0.64 to 0.989.

Conclusions

It is possible to simulate five- to six-month daily assessment of pain in SCD. Either one-day-per-week or one-week-per-month assessment yields an equivalent mean and fair regression equivalence.

Optimizing Digital Integrated Care via Micro-Randomized Trials

Mobile health (mHealth) interventions are a promising tool in providing digitally mediated integrative care. They can extend care outside of the clinic by providing reminders to take medications, assisting in managing symptoms, and supporting healthy behaviors including physical activity, healthy eating, and stress management. mHealth interventions can adapt the delivery of care across time in order to optimize treatment effectiveness. Yet there exists limited empirical evidence useful to the development of adaptive mHealth interventions. This article describes a new randomized trial design, the Micro-Randomized Trial (MRT), for informing the development of mHealth interventions. We provide examples of scientific questions important to the development of an mHealth intervention, and describe how these questions can be answered using an MRT.

The Revised Child Anxiety and Depression Scale: A systematic review and reliability generalization meta-analysis

BACKGROUND

Anxiety and depression are among the most common mental disorders during childhood and adolescence. Among the instruments for the brief screening assessment of symptoms of anxiety and depression, the Revised Child Anxiety and Depression Scale (RCADS) is one of the more widely used. Previous studies have demonstrated the reliability of the RCADS for different assessment settings and different versions. The aims of this study were to examine the mean reliability of the RCADS and the influence of the moderators on the RCADS reliability.

METHODS

We searched in EBSCO, PsycINFO, Google Scholar, Web of Science, and NCBI databases and other articles manually from lists of references of extracted articles.

RESULTS

A total of 146 studies were included in our meta-analysis. The RCADS showed robust internal consistency reliability in different assessment settings, countries, and languages. We only found that reliability of the RCADS was significantly moderated by the version of RCADS. However, these differences in reliability between different versions of the RCADS were slight and can be due to the number of items.

LIMITATIONS

We did not examine factor structure, factorial invariance across gender, age, or country, and test-retest reliability of the RCADS.

CONCLUSIONS

The RCADS is a reliable instrument for cross-cultural use, with the advantage of providing more information with a low number of items in the assessment of both anxiety and depression symptoms in children and adolescents.